RT Clinic: APRV start-up, management, and weaning

[@lauradavis1479]

Amazing video! Thank you so much for posting educational videos. It helps soon to be RT’s such as myself. Which then leads to properly helping patients. Thank you so much!

[@martiniasmith1446]

Makes more sense. You get right to the point.

[@colleencar2249]

This was great ! I needed a refresher on APRV . Feeling more confident . Thank You !

[@kennethweiss9068]

Watched for second time;so much great info. Ty!!

[@bishnya21]

Thank you!!! I tried it on my covid patient that kept breath stacking on every mode & her pao2 pretty much doubled from 54 to 122

[@LitanyofFury99]

Who's here because of COVID 19?

[@rtclinic]

The views are way up right now.. my guess is about 90% of views are related to COVID.

[@D1G1TALSYNAPS3]

09:38 “I’m a respiratory therapist...it’s alright.” Man I’m dead. This is verbatim what I say.

[@peterfslife]

Thank You for the assistance. You truly make GREAT VIDEOS!! You need to do more! A LOT MORE Respiratory videos!!!!

[@peterfslife]

Jimmy? I'm one of you frequent viewers, as I watch your videos ALL THE TIME!! I told you my story years ago, but I don't see a video on standard ventilator weaning, so I think I'll ask my question here. OK! So as You know, ventilators like THAT ONE, the Drager V500, have the capability to perform Respiratory Mechanics, such as a NIF, or a PO.1 maneuver. Now Lots of the modern ventilators like the Drager Series, the Puritan Bennetts, such as the PB980, or the older PB840, and even the old PB7200, have the capability to do this NIF maneuver. Now on the 7200, I think it's called a MIP maneuver. But my question is, which do you think is more accurate? The use of the Ventilator to conduct a NIF maneuver, or using those stand alone NIFometers as they're called? Now I happen to have in a drawer behind me, a Mercury Medical NIFometer. It is a disposable device, and there's a patient occlusion button that occludes the airway. people still use those things now days. Even at a regional hospital I go to they have a PB840, and they're still taking the patients off to perform a NIF! What do you think is more Accurate?NIF from the Ventilator, or NIF from a NIFometer?

[@rtclinic]

I would say the NIf from a nifometer would be more accurate. I sometimes question the vent value. 😕

[@solodeking]

Thanks Jimmy for a brilliant elucidation. So, a patient has to be started on VC-AC so as to determine the Pplat before switching on to APRV? And we are doing all this fir a spontaneously breathing patient, who is not paralyzed, but adequately sedated. Right?

[@rtclinic]

This would be the ideal situation. We have also used APRV on paralyzed patients with strict monitoring of minute ventilation. An ABG on VC/AC preAPRV will give a good indication of where the minute ventilation needs to be in APRV.

[@solodeking]

@@rtclinic Thanks a bunch. Thought as much, but wanted to be sure.

[@maxineagina]

Amazing! Thank you! I’ve finally understood this mode!

[@peterfslife]

Your videos are GREAT! I have a question. Ok. When a patient is on a Ventilator obviously, they have the Circuit secured on the support arm. Let’s say you have s Trach patient who is awake and alert and able to move some. You want the patient to have comfort without too much pull on the Trach. How tight to you tighten the support arm screw device? Should the arm be able to swing easily, or kept tight??

[@rtclinic]

Thanks for the question Peter. I think the arm should be firm. I would attach the adapter to the circuit closer to the ventilator than the patient to allow the circuit to move with the patient. The swinging arm worries me a bit just for patient safety. These devices are excellent for these situations and usually come with the trach ties. tri-anim.com/antidisconnect-device-tracheotomy-trachstay--product-22313-3791.aspx?search=103-11270EA

[@mujobella5770]

Can you explain why the flowcurve looks like that?

[@rtclinic]

The flow curve is very odd with APRV. I usually use the pressure time waveforms to analyze this mode.

[@Desiree6811]

Very easy to understand! Thank you!

[@aundreahenry8139]

What is the best way to keep them comfortable using this mode? What type of sedation are you using?

[@rtclinic]

We've used Versed or Diprivan in the past including and analgesic. It is not recommended, but the best results have been when we paralyze the patient. If an adequate Ve can be maintained to eliminate CO2, this if the best option to truly rest the pulm system. It is good for a short amount of time to get them through the refractory hypoxemia before stopping the paralytic.

[@gabmor7779]

i tried aprv on some covid patients and in one patient in particular the fio2 went from 70 to 40 within couple hours!! i just wonder about lung protection with those higher mean airway pressures, but listening to dr.habashi is it rather more lung protective compared to standard ards ventilation. oh well who knows. sure is interesting

[@rtclinic]

It's a great option when the patient's issue is purely oxygenation. APRV should be tried earlier, but is usually used when everything has been maxed on VC.

[@gabmor7779]

@@rtclinic I tried it only on patients once they were quite far into their disease progress thats true. And i noticed that keeping the termination of expiration at 75% is quite hard, sometimes less than 0,2 seconds ( our machines didnt allow less than 0,2). I also noticed several times how the peak expiratory flow would have a deep dip , almost a horizontal dip to about 100l/min then go back up around 60l/min and then have an 45 degree angle . Is that usually an artifact and i should check for kinks in the tube or suction? or is that normal in severe damaged lungs ( wish i could post a pic,)

[@solodeking]

Hello Gab, with APRV, the pressure reduces over time as the lung compliance improves and more alveoli are recruited, so the trans-pulmonary pressure reduces and oxygenation improves or at worst, stays the same. I think APRV offers a better lung protective strategy, but needs to be initiated early.

[@rtclinic]

@@gabmor7779 sorry for the late response. Send a pic to my email [e-mail]. I've seen some funky waveforms on a few patients in the past.

[@ashleyharmon3158]

Can you do a video showing the modes for VC and PC? I'm learning that in school right now and I seem to be struggling.

[@rtclinic]

Just PC vs VC? Any other modes that you are having trouble with?

[@rahaf8115]

Great explanation 👍🏻

[@peterfslife]

Hi. I know my question isn’t related to APRV but could you please respond!!? Your videos are GREAT!!!

[@petite_stacey]

Thank you so much for this video

[@greensahuaro2834]

Thanks!

[@victoriatorres400]

Great review! Thank you.

[@sinclair657]

Ehank you

[@BasicRRT]

Please do Prvc and Hamilton G5.

[@rtclinic]

I would love to...but I do not have access to a G5.

[@BasicRRT]

@@rtclinic Thank you anyway, you're videos are super helpful

[@RossMac023]

what about PEEP?

[@rtclinic]

PEEP isn't set in APRV. It is measured by performing an expiratory hold and measuring an intrinsic PEEP level. If you notice the pressure waveform doesn't reach baseline between releases. The pressure level at the bottom of that valley is the PEEP level. It can be increased by decreasing the TLOW and can be decreased by increasing the TLOW. In easier terms...a long TLOW will allow for the pressure to come closer to baseline. I hope this helps!

[@steves8860]

Relying on Auto PEEP seems dangerous since all lung units are not the same. Since the compliance is subject to change, and thus the AutoPEEP would change as well at a given Time Low, why not set a PEEP that still allows your flow to decrease by 75%? This could be done by increasing PEEP until the flow doesn't get to the 75% point and then back it down slightly. Id think that this would help prevent some units from closing and being snapped back open. Just a little bit of safety possibly?

[@rtclinic]

This is a good suggestion as long as the RT continues to monitor the percentage of flow decrease as compliance changes. All RTs caring for the patient would all need to be on the exact same page.

[@ericerickson4876]

Not a ve thought out presentation.

[@ronaldshiffman9120]

I have 34 years of bedside respiratory therapy experience and have worked with hundreds of patients on APRV. This mode HAS NEVER been shown to be as good or better than other more conventional ventilatory modalities. I would never use it on a patient if I were an MD. Think about it physiologically. It violates every known principle of breathing. APRV makes no sense in the real world and should never be used.

[@solodeking]

You don't seem to have been following the outcome with covid-19 patients who got conventional ventilatory modalities when compared with those who got CPAP, APRV or simply HFNC. I think it is an awesome lung protective mode if and only if you get the settings right, with lesser adverse outcomes.

[@rtclinic]

I appreciate your comment. I've seen APRV greatly improve oxygenation without the increased barotrauma. I agree that it is very, very different than any other mode.

[@ronaldshiffman9120]

@@solodeking I wonder where you live and manage ventilators? Not a criticism, just a question. I have never worked with a Covid-19 patient. I have been retired for 2 years. I have, however, worked with hundreds of patients on APRV for thousands of hours. I bet I have done as much bedside ventilator care as anyone - on all kinds of patients. The current state of affairs in pulmonary/ventilatory medicine is not good (look at the outcome mortality rate). Buzz words like 'lung protective' serve the pulmonology hieracrchy because protecting lungs has to be good, right, but actual outcome mortality has not improved in 20 years.